key points in the treatment of chronic kidney disease
DESCRIPTION
KEY POINTS IN THE TreatMENT OF Chronic Kidney Disease. CHET FOX MD PROFESSOR OF FAMILY MEDICINE UNIVERSITY AT BUFFALO. Background. The Burden of CKD. CKD affects 26 million Americans Prevalence is 11-13% It consumes 28% of the Medicare Budget This was 6.9% in 1993 - PowerPoint PPT PresentationTRANSCRIPT
CHET FOX MDPROFESSOR OF FAMILY MEDICINE
UNIVERSITY AT BUFFALO
CKD affects 26 million Americans Prevalence is 11-13% It consumes 28% of the Medicare Budget
This was 6.9% in 1993 Costs for 2013 were $42 Billion dollars
DM+ CKD increases mortality rate 6 fold CKD disproportionally affects African
Americans and Hispanicshttp://usrds.org
Hypertension Diabetes CAD Family History
CKD African
American Elderly Morbid Obesity
eGFR
ACRAlbumin/Creatinine ratio
•A GFR loss of > 1 mL/min/year beginning at age 25 can result in end-stage renal disease within a normal lifespan.
Lee A Hebert et al. Kidney International (2001) 59, 1211–1226
CVD
HYPERTENSION
DIABETES CKD
HTN AND DM ARE THE LEADING HTN AND DM ARE THE LEADING CAUSE OF CKDCAUSE OF CKD
Two New England Journal publications indicate that Cardiovascular survival is directly related to a patient’s kidney function!!
NS Anavekar, et al. N Engl J Med 2004;351:1285-95AS Go, et al. N Engl J Med 2004;351:1295-305
CKD
HYPERTENSION
DIABETES
PROTEINURIA
SAVE YOUR KIDNEYS AND SAVE YOUR HEART
ANEMIABONE DISEASE
Diagnosis Recognition of
Complications Medication
Safety Treatment Preparation for
Vascular Access When to Refer
GD is a 63 year old African American female with poorly controlled HTN, DM, increased lipids, obesity, GERD , gout, and sleep apnea. She has not had an MI (yet) She smokes ½ PPD
Meds include Amlodipine 10 qd, HCTZ 25 qd, Clonidine 0.3 bid, Atorvastatin 10, Metoprolol 100 bid, Insulin glargine 30 at HS, Metformin 1000 po bid, Allopurinol 300 qd, L, Omeparazole 20 qd, and CPAP at 12 cm (Note: she is not on an ACE)
BP is 150/86; Labs: HbA1C is 10.4; Hb is 9.5, HDL
is 35, LDL is 115, triglycerides are 295; Ca is 9.8; Microalbumin/creatinine ratio is 54.5; Creatinine is 1.7: GFR = 39
GD has stage 3 CKD and most of it’s complications.
What should we do for this patient?
Microalbumin/Creatinine >30GFR < 60GD has Stage 3B;A2 CKDThis puts her at moderately high risk
HYPERLIPIDEMIA
HYPERTENSION
DIABETES
PROTEINURIA
ANEMIA BONE LOSSKIDNEY DZ
There are meds that are dangerous to her: We stop them or modify dose
GD is taking OTC NSAIDS for her back pain We stop this and all
NSAIDS and Cox-2 Metformin can cause lactic
acidosis. We stop if GFR < 30
We reduce her Allopurinol We avoid Bisphosphonates
ACE is added to reduce proteinuria and delay CKD progression. GFR decreases to 32 but
stays there. Creat is 2.1 K+ is good at 4.0 We leave her on the ACE
Her BP goes down to 130/70
We stop her clonidine as it is no longer need
She starts a diet and exercise program We encourage patient
centered goal setting (Motivational Interviewing)
We intensify her insulin regimen
We add Sitagliptin, liraglutide, or glypizide to her insulin
Her HbA1C drops to 6.8 over 6 months
We increase her statin to Atorvastatin 40 mg qd
We start ASA 81 mg qd We give her the ACS quit
smoking line number We add Niaspan 500 qd
or Omega 3’s One gram bid to raise HDL and decrease Triglycerides
She quits smoking, Her HDL is now 43, LDL 68 and Triglycerides 130
Colonoscopy is normal MCV is nl at 85 Fe is 50; TIBC is 200 for a
saturation of 25% We start Erythropoieitin 20,000
units q 2 weeks We start oral iron √CBC ,Fe/TIBC monthly. We hold
EPO if Hb > 12.0 Hb rises to 11.5 and she feels
much better Transferrin saturations stay
normal at above 20%
We √ Ca++; PO4=; and PTH and 25
OH Vit D levels Ca++ is 9.8 (nl) PO4
= is 3.1 (nl) PTH is 60 (nl) Vit D is 7 (low) We start her Vit D 50,000 units
once per month or 1,000-2,000 units daily
We follow these labs yearly and refer if PTH > 100 or PO4
= rises above 4.5
We remember “Fistulas first and Catheters Kill”
We tell her to to use the back of her hand for blood draws
We refuse to allow any PICC lines to be put in when GFR < 45.
We refer her to nephrology when GFR < 30
If the GFR <20; we refer for transplant evaluation even before she needs dialysis
She does not have a heart attack
She lost 30 pounds Her kidney disease stabilizes She feels better and has more
energy We delay the need for dialysis She does not get a hip fracture If she does progress, she will
be referred early
Use GFR, Urine Microalbumin to diagnose CKD
If GFR < 60 or Microalbumin/creat > 30 start ACE (If cough on ACE, start ARB)
Avoid NSAIDS Refer to Nephrology for GFR < 30 Refer for Transplant evaluation for GFR <
20 Promote smoking cessation Keep BP < 140/90 Keep HbA1C < 7.0 Keep LDL < 100 Avoid PICC lines for GFR < 45
Check Calcium, Phosphorous, PTH, and Vit D yearly
Check Hemoglobin yearly If iron is normal, start erythropoietin
if Hb< 10 or refer to Nephrology Refer to Nephrology for
Phosphorous >4.5 or PTH > 100
GFR< 30 Rapidly deteriorating kidney
function Marked proteinuria Difficult-to-control hypertension PTH > 100 or Phosphate > 4.5 GFR < 20; Refer for Transplant
evaluation
eGFR What to do
>60 and microalbumin< 30 Yearly surveillance with GFR (for hypertensive patients) and both GFR and microalbumin (for diabetic patients)
>60 and microalbumin > 30 ACE or ARB
>45 and < 60* ACE or ARB Discontinue NSAIDS ? off Metformin** Check hemoglobin Check Calcium, Phosphorous, PTH and
Vitamin D yearly>30 and < 45 The above plus
Stop metformin** No PICC lines All blood draws from dominant arm (Save an
Arm)
< 30 Refer to Nephrologist
< 20 Refer for transplant evaluation
* Need 2 consecutive GFR <60 at least 3 months apart to diagnose CKD. If the patient does not have risk factors of hypertension, diabetes, family history or coronary disease, this might be a false positive test.
*Treat hypertension, diabetes, and hyperlipidemia the same way you would treat a diabetic patient.
**Metformin does not cause progression of CKD, but it increases the risk of lactic acidosis.